Out on Pass Form

Out On Pass Request Form
Date*

MonthDayYear
Date
What type of stay is the resident here for?*

Short Term RehabLong Term Care
The resident was admitted to Cold Spring Hills for a skilled stay to be rehabilitated. Insurance has approved this rehabilitation as they feel it is necessary for the well-being of the resident. Short-term residents going out for social visits or other non-medical-related appointments are discouraged from going out. The particular insurance carrier may deem a social visit or non-medical outing as a reason to deny the claim for the rehabilitative services resulting in immediate discharge from Cold Spring Hills.

If you are requesting clearance for a medical appointment, please reach out to the medical clinic for further instructions. They can be reached at 516-622-7735.
Do you agree and understand the above?*

YesNo

Pass Information
What type of pass are you requesting?*

Day Pass (return before 11:59 p.m.)Overnight Pass (return before 11:59 p.m. on designated day)
What is the purpose of this pass?*

Medical AppointmentSocial Appointment / Other
What method of transportation is being used?*

Ambulette / AmbulanceCar / Vehicle / Uber
Please note, the facility does not arrange transportation for out on pass requests. You would be required to set up your own transportation as needed. Here are some numbers of local companies that may be able to assist:
- Plainview Taxi & Airport Service - (516) 500-1188
- Woodbury Taxi and Airport Service - (516) 200-6446
- Islandwide Taxi - (631) 547-0707
- Choice Medical Transport - (631) 342-8888
- Ricar Medical Transport - (631) 737-1542
- Century Ambulette - (516) 576-3270
Date of Pass*

MonthDayYear
Date
Time of Departure*

Hour Minutes

AM/PM Option
Date of Return*

MonthDayYear
Date
Estimated Time of Return*

Hour Minutes

AM/PM Option
Date Calculation
**Error: Your return date must be after your departure date**
What is the destination?*

Resident Information
Resident's Name*
Resident's Cell Phone Number*
Please enter a valid phone number.
Which Unit is the Resident On?*
Which Room Number?*
Is this independent or escorted by someone?*

Resident is going out independentResident will be escorted by an able bodied representative

Any Additional or Special Information We Should Know?
Please provide your email if you would like to be updated on the status of this request.
example@example.com

Out On Pass Request Form